MAUDE Adverse Event Report: RXSIGHT, INC. LIGHT ADJUSTABLE LENS (LAL)

Model Number	60005
Medical Device Problem Code	Insufficient Device Problem Information (3190)
Health Effect - Clinical Code	Visual Impairment (2138)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The site reported that the light adjustable lens was explanted from the patient.No additional information was provided as to the reason for the explant.Rxsight's first awareness was on (b)(6) 2021.The device history record of the lens was reviewed.No issues were noted.The lens is currently being evaluated.
Event or Problem Description
The site reported that the light adjustable lens was explanted from the patient.No additional information was provided as to the reason for the explant.Rxsight's first awareness was on (b)(6) 2021.
Additional Manufacturer Narrative
The site reported that the light adjustable lens was explanted from the patient.No additional information was provided as to the reason for the explant.Rxsight's first awareness was on (b)(6) 2021.The device history record of the lens was reviewed.No issues were noted.The lens is currently being evaluated.
Event or Problem Description
The site reported that the light adjustable lens was explanted from the patient.No additional information was provided as to the reason for the explant.Rxsight's first awareness was on (b)(6) 2021.
Additional Manufacturer Narrative
The site reported that the light adjustable lens was explanted from the patient.No additional information was provided as to the reason for the explant.Rxsight's first awareness was (b)(6) 2021.Visual inspection of the returned lens found the lens had been cut into multiple fragments.Visual inspection and optical testing of the lens found no issues with the lens.
Event or Problem Description
The site reported that the light adjustable lens was explanted from the patient.No additional information was provided as to the reason for the explant.Rxsight's first awareness was (b)(6) 2021.

• Brand Name: LIGHT ADJUSTABLE LENS (LAL)
• Common Device Name: LIGHT ADJUSTABLE LENS (LAL)
• Manufacturer (Section D): RXSIGHT, INC.; 100 columbia; aliso viejo CA 92656
• Manufacturer (Section G): RXSIGHT, INC.; 100 columbia; aliso viejo CA 92656
• Manufacturer Contact: kelli carrillo ; 100 columbia; aliso viejo, CA 92656
• MDR Report Key: 13056462
• Report Number: 3012712027-2021-00088
• Device Sequence Number: 3951424
• Product Code: PZK
• UDI-Device Identifier: 00818806020050
• UDI-Public: 01008188060200501121011117231231
• Combination Product (Y/N): N
• Initial Reporter State: PA
• Initial Reporter Country: US
• PMA/510(K) Number: P160055
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: User Facility
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 12/17/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Health Professional
• Device Expiration Date: 12/31/2023
• Device Model Number: 60005
• Device Catalogue Number: 60005
• Device Lot Number: L02-001984
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 12/03/2021
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Follow-Up
• Initial Date Received by Manufacturer: 12/03/2021
• Supplement Date Received by Manufacturer: 12/03/2021
• Initial Report FDA Received Date: 12/21/2021
• Supplement Report FDA Received Date: 03/02/2022
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 01/11/2021
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other
• Patient Sex: Unknown